1
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Kumar N, Mishra R, Bargali A, Bhavana RI. Dengue-associated longitudinally extensive transverse myelitis. BMJ Case Rep 2024; 17:e259388. [PMID: 38531558 DOI: 10.1136/bcr-2023-259388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
We diagnosed a patient with dengue fever who developed acute onset of sensorimotor quadriparesis with bladder involvement, and facial nerve involvement. Despite initial negative results in routine investigations and cerebrospinal fluid analysis, spinal MRI confirmed longitudinally extensive transverse myelitis. The aetiological workup was negative, prompting an investigation into the presence of dengue in the cerebrospinal fluid, which returned positive. This case underscores the importance of considering rare neurological complications in dengue, the value of advanced diagnostic techniques and the potential effectiveness of tailored interventions in challenging cases.
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Affiliation(s)
- Naresh Kumar
- Medicine, Maulana Azad Medical College, New Delhi, Delhi, India
| | - Rashmi Mishra
- Medicine, Maulana Azad Medical College, New Delhi, Delhi, India
| | - Arun Bargali
- Medicine, Maulana Azad Medical College, New Delhi, Delhi, India
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2
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Patel P, Turbin RE, Husain S, Wang S. Neurosyphilis Mimicking Connective Tissue Disease. BMJ Case Rep 2023; 16:e256301. [PMID: 37770241 PMCID: PMC10546142 DOI: 10.1136/bcr-2023-256301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
A male in his 60s developed a pruritic, maculopapular rash on his torso and arms, sparing his palms and soles. He tested positive for ANA and an initial skin biopsy identified "bullous lupus," supporting the diagnosis of a connective tissue disease. Additional symptoms included headaches, facial nerve palsy and hearing loss, which partially responded to oral corticosteroids. He subsequently developed a steroid-dependent left eye scotoma, neuroretinitis and optic nerve papillitis. Mycophenolate mofetil was added but an attempted oral steroid taper led to a worsening rash, progressive retinitis and papillitis. Neurosyphilis was confirmed by serum positive rapid plasma reagin test, reactive treponema pallidum antibodies, positive cerebrospinal fluid venereal disease research laboratory and positive spirochete immunostain of skin biopsy of lesional (rash) tissue. Treatment with intravenous ceftriaxone resolved his rash and visual symptoms. It is important to consider syphilis as a mimicker of connective tissue diseases.
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Affiliation(s)
- Pooja Patel
- Internal Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Roger E Turbin
- Department of Ophthalmology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Sameera Husain
- Division of Dermatopathology, Columbia University, New York, New York, USA
| | - Shuwei Wang
- Division of Rheumatology, Department of Medicine, VA New Jersey Health Care System, East Orange, New Jersey, USA
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3
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Perrott S, Khan QI, Counsell CE, Macleod AD. Progressive multifocal leukoencephalopathy associated with carbamazepine-induced immune dysfunction and recovery after carbamazepine cessation. BMJ Case Rep 2023; 16:e255119. [PMID: 37419500 DOI: 10.1136/bcr-2023-255119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023] Open
Abstract
A patient with epilepsy on carbamazepine developed a rapidly progressive cerebellar syndrome. Serial MRI showed progressive posterior fossa T2/fluid attenuated inversion recovery hyperintensity with gadolinium enhancement. Standard cerebrospinal fluid (CSF) analysis was normal. Detection of John Cunningham virus DNA in the CSF confirmed progressive multifocal leukoencephalopathy (PML). The only evidence of immune disfunction was hypogammaglobulinaemia and longstanding lymphopenia. After cessation of carbamazepine, the lymphocyte count and immunoglobulin levels returned to normal and the PML resolved, with good clinical recovery. No specific treatments for PML were given. We hypothesise that PML in this case was due to carbamazepine-induced prolonged mild immunosuppression with reconstitution of the immune system after carbamazepine cessation, resulting in recovery from PML. Effects of anticonvulsants on immune function and infection risk may contribute to epilepsy-related morbidity and mortality. Further investigation is needed to determine the frequency of immune dysfunction and infections in patients treated with anticonvulsants such as carbamazepine and whether interventions could reduce infection risk.
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Affiliation(s)
- Sarah Perrott
- School of Medicine Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | - Carl E Counsell
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
| | - Angus D Macleod
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
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4
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Enwo OO, Ibrahim D, Boughton M, Coyle-Gilchrist I. Varicella zoster virus cerebellitis without skin manifestations in an immunocompetent adult. BMJ Case Rep 2023; 16:16/1/e252636. [PMID: 36717159 PMCID: PMC9887685 DOI: 10.1136/bcr-2022-252636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The varicella zoster virus (VZV) is a ubiquitous, neurotropic pathogen capable of reactivation from sensory ganglion cells to cause dermatomal herpes zoster infection, alongside a range of pathologies within the central nervous system. The presence of VZV cerebellitis without skin manifestations, however, is exceedingly rare in immunocompetent adults.We report a case of VZV cerebellitis in an immunocompetent woman in her 70s, in the absence of a rash. The patient presented with a 2-week history of progressive gait ataxia, headache and mild confusion. Serological tests and neuroimaging were unremarkable. Diagnosis was confirmed through cerebrospinal fluid (CSF) analysis which revealed lymphocytosis and the presence of VZV DNA on PCR analysis. The patient showed symptomatic improvement following empirical acyclovir treatment, corroborated by favourable CSF analysis 10 days post-treatment initiation.Infective aetiology, including VZV, should be considered in patients presenting with acute cerebellar ataxia, even in immunocompetent adults with an absence of dermatological signs.
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Affiliation(s)
- Oby Otu Enwo
- Norwich Medical School, University of East Anglia, Norwich, UK .,Neurology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Dina Ibrahim
- Neurology, Norfolk and Norwich University Hospital, Norwich, UK
| | | | - Ian Coyle-Gilchrist
- Norwich Medical School, University of East Anglia, Norwich, UK.,Neurology, Norfolk and Norwich University Hospital, Norwich, UK
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5
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Chakraborty U, Santra A, Pandit A, Dubey S, Chandra A. Space occupying lesion presenting as Millard-Gubler syndrome. BMJ Case Rep 2022; 15:e248590. [PMID: 35414579 PMCID: PMC9006827 DOI: 10.1136/bcr-2021-248590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2022] [Indexed: 11/04/2022] Open
Abstract
Millard-Gubler syndrome (MGS) is a ventral pontine syndrome due to an ipsilateral involvement of abducens and facial nerve with a contralateral hemiparesis or hemiplegia. Although classically described as a vascular brainstem syndrome, various other aetiologies such as infection or demyelination may lead to MGS. In this case, a young female presented with MGS, which was attributed to a strategically located infective granuloma of the brainstem. In countries, where tuberculosis is still considered an endemic, central nervous system involvement due to tuberculosis may have protean manifestations.
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Affiliation(s)
- Uddalak Chakraborty
- Department of Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurology, Kolkata, West Bengal, India
| | - Arindam Santra
- Department of Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurology, Kolkata, West Bengal, India
| | - Alak Pandit
- Department of Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurology, Kolkata, West Bengal, India
| | - Souvik Dubey
- Department of Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurology, Kolkata, West Bengal, India
| | - Atanu Chandra
- Department of Internal Medicine, RG Kar Medical College and Hospital, Kolkata, West Bengal, India
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6
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Siddiqui AF, Saadia S, Ejaz T, Mushtaq Z. COVID-19 encephalopathy: an unusual presentation with new-onset seizure causing convulsive status epilepticus. BMJ Case Rep 2022; 15:15/3/e245387. [PMID: 35260396 PMCID: PMC8905954 DOI: 10.1136/bcr-2021-245387] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Although neurological manifestations such as headache and myalgias have been observed with COVID-19, presentation with more serious neurological illness is uncommon and rare. We report a case of a middle-aged woman who presented to the emergency department of a tertiary care hospital. Her clinical presentation was primarily neurological rather than the more common presentation with respiratory manifestations. She presented with generalised tonic–clonic seizures, along with history of undocumented low-grade fever and generalised body aches. The positive SARS-CoV-2 RT-PCR nasal swab, the cerebrospinal fluid analysis (lymphocytic pleocytosis) and electroencephalogram were consistent with viral encephalitis; brain imaging was unremarkable. This case highlights the variable presenting features of COVID-19 infection as patients can primarily present with neurological manifestations in the absence of significant respiratory symptoms. We believe it is important to recognise neurological disease associated with SARS-CoV-2 in patients with asymptomatic respiratory infection.
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Affiliation(s)
- Aisha Fareed Siddiqui
- Section of Internal Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
| | - Sheema Saadia
- Section of Internal Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
| | - Taymmia Ejaz
- Section of Internal Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
| | - Zain Mushtaq
- Section of Internal Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
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7
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Nakamura Y, Honda D, Takizawa N, Fujita Y. Herpes zoster meningitis in a rheumatoid arthritis patient treated with tofacitinib. BMJ Case Rep 2022; 15:e247276. [PMID: 35236687 PMCID: PMC8895891 DOI: 10.1136/bcr-2021-247276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 12/30/2022] Open
Abstract
A man in his 70s with rheumatoid arthritis presented with seizures and coma and was transferred to our emergency department. Two months prior to admission, he started to take tofacitinib 10 mg/day. On admission, we noted a rash with a blister on the forehead, and herpes zoster was diagnosed. Cerebrospinal fluid examination suggested meningitis. An MRI of the brain showed no abnormality. Based on these findings, he was suspected with herpes zoster meningitis. We discontinued tofacitinib and treated the patient with intravenous acyclovir for 2 weeks. He regained complete consciousness, but right forehead skin lesion, severe vision loss in the right eye and right facial nerve paralysis remained as sequelae. Six weeks after admission, we restarted tofacitinib with oral valaciclovir as antiviral prophylaxis. Two years after admission, we administered Shingrix, an adjuvant recombinant vaccine for herpes zoster, and discontinued oral valaciclovir.
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Affiliation(s)
| | - Daiyu Honda
- Department of Neurology, Nagoya Daiichi Sekijuji Byoin, Nagoya, Aichi, Japan
| | - Naoho Takizawa
- Department of Rheumatology, Chubu Rosai Hospital, Nagoya, Aichi, Japan
| | - Yoshiro Fujita
- Department of Rheumatology, Chubu Rosai Hospital, Nagoya, Aichi, Japan
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8
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Wassef C, Johnson A, Stone J. Unusual case of spinal subdural empyema with ventriculitis managed conservatively with lumbar drain. BMJ Case Rep 2022; 15:e247156. [PMID: 35228235 PMCID: PMC8886382 DOI: 10.1136/bcr-2021-247156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2022] [Indexed: 11/04/2022] Open
Abstract
It has long been believed that spinal subdural empyemas (SDEs) with neurological symptoms result in death if operative intervention is not performed. We present a case of addressing an extensive spinal SDE with a minimally invasive procedure: a bedside lumbar drain. Our patient is a 67-year-old man with medical history significant for type I diabetes who presented 2 weeks after a right shoulder steroid injection with septic arthritis. An MRI was obtained for back pain which revealed spinal SDE from the cervical to lumbosacral spine. Given patient's acute sepsis, haemodynamic instability, and extent of empyema, we placed a lumbar drain for decompression. The patient had a prolonged complicated hospital course. Imaging 2 months later revealed interval decrease in the spinal SDE. Although this severe septic event left the patient with significant deficits, he was able to return to ambulation without surgical intervention.
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Affiliation(s)
- Catherine Wassef
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Angelique Johnson
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jonathan Stone
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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9
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Silva DH, Banganho D, Moreira B, Silva AG. Varicella-zoster virus infection: more than just a rash. BMJ Case Rep 2022; 15:e247006. [PMID: 35228233 PMCID: PMC8886380 DOI: 10.1136/bcr-2021-247006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/03/2022] Open
Affiliation(s)
- Diana H Silva
- Department of Pediatrics, Hospital de São Bernardo, Centro Hospitalar de Setúbal EPE, Setubal, Portugal
| | - Denise Banganho
- Department of Pediatrics, Hospital de São Bernardo, Centro Hospitalar de Setúbal EPE, Setubal, Portugal
| | - Biana Moreira
- Department of Pediatrics, Hospital de São Bernardo, Centro Hospitalar de Setúbal EPE, Setubal, Portugal
| | - Ana Gomes Silva
- Department of Pediatrics, Hospital de São Bernardo, Centro Hospitalar de Setúbal EPE, Setubal, Portugal
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10
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Furtado LM, Costa Val Filho JA, Simas RT, Ferreira JPU. Suboccipital extracranial and intracranial abscess of a neonate: an exceedingly rare occurrence. BMJ Case Rep 2022; 15:e246929. [PMID: 35131791 PMCID: PMC8823085 DOI: 10.1136/bcr-2021-246929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 11/03/2022] Open
Abstract
Intracranial abscess is a life-threatening disease that is uncommon in paediatric populations. Although there have been few reports in the literature, some aetiologies, such as mastoiditis and sinusitis, have been proposed. The pathophysiology is not completely known, and there are no data regarding the long-term follow-up of these patients. Herein, we present a case of a newborn affected with a mass in the suboccipital region due to an extracranial and intracranial abscess that had no clear association with infections except for a transient fever episode 1 month earlier. Isolation of Staphylococcus aureus from an open-surgery sample identified the cause of the mass. The patient achieved excellent recovery with no recurrence even after 8 years of follow-up. To our knowledge, this rare pattern of infection highlights the importance of early diagnosis in combination with a surgical approach as an effective diagnosis and treatment approach that provided a good outcome.
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Affiliation(s)
- Leopoldo Mandic Furtado
- Neurosurgery, Fundacao Hospitalar do Estado de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- Pediatric Neurosurgery, Hospital Vila da Serra, Nova Lima, Minas Gerais, Brazil
| | | | - Rayane Toledo Simas
- Pediatric Neurosurgery, Vila da Serra Hospital, Nova Lima, Minas Gerais, Brazil
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11
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Abstract
Adverse events occurring after SARS-CoV-2 vaccination have been reported and are the subject of ongoing research. We present the case of a young woman with fully reversible radiculomyelitis, which happened after the first dose of the ChAdOx1 nCOVID-19 vaccine. A previously healthy woman in her 20s presented with a subacute onset of legs’ weakness and sensory disturbances, urinary dysfunction and cramping pain after receiving the first dose of the ChAdOx1 nCoV-19 vaccine. A diagnostic workup led to the diagnosis of inflammatory radiculomyelitis. Her clinical status improved, with complete recovery after a few months. The case described a reversible radiculomyelitis associated with the ChAdOx1 nCOVID-19 vaccine. The clinical picture and evolution supported the diagnosis. No other identifiable causes of myelopathy were found. Our patient showed clinically moderate symptoms and signs, showing good recovery. The post-vaccine inflammatory radiculomyelitis is a rare side effect of the anti-COVID-19 vaccination, and it should not discourage the SARS-CoV-2 vaccination programme.
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Affiliation(s)
- Rossella Spataro
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, ALS Clinical Research Center, University of Palermo, Palermo, Italy.,IRCCS Centro Neurolesi Bonino Pulejo, Palermo, Italy
| | - Giacomo Fisco
- IRCCS Centro Neurolesi Bonino Pulejo, Palermo, Italy
| | - Vincenzo La Bella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, ALS Clinical Research Center, University of Palermo, Palermo, Italy
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12
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Nelles R, Britton S, John GT, Denaro C. Parkinsonism and prolonged cognitive decline as a manifestation of cryptococcal meningitis in a renal transplant patient. BMJ Case Rep 2022; 15:e245788. [PMID: 35046073 PMCID: PMC8772404 DOI: 10.1136/bcr-2021-245788] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2021] [Indexed: 11/04/2022] Open
Abstract
We report a case of a 67-year-old male recipient of a second renal allograft, presenting with a 9-month history of progressive cognitive and physical decline with features of Parkinsonism. He was HIV-negative. Serum and cerebrospinal fluid (CSF) cryptococcal antigen was positive though CSF culture was sterile. He had progressive deterioration despite induction and consolidation antifungal treatment. Postmortem brain examination confirmed a large burden of yeast forms in the substantia nigra with widespread chronic meningitis. The significant delay in presentation and diagnosis owing to the atypical, subacute neurocognitive features serves as a timely reminder of the variety of neurological presentations that may be associated with cryptococcal infection in solid organ transplant recipients.
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Affiliation(s)
- Ricky Nelles
- Haematology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Sumudu Britton
- Infectious Disease Unit, Royal Brisbane Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, Queensland, Australia
| | - George Tharayil John
- Faculty of Medicine, The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, Queensland, Australia
- Renal Unit, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - Charles Denaro
- Faculty of Medicine, The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, Queensland, Australia
- Department of Internal Medicine & Aged Care, Royal Brisbane Hospital, Herston, Queensland, Australia
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13
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Sajjad A, Khan AF, Jafri L, Kamal AK. Successful endovascular mechanical thrombectomy in anticoagulation-resistant COVID-19 associated cerebral venous sinus thrombosis. BMJ Case Rep 2021; 14:14/12/e245405. [PMID: 34972772 PMCID: PMC8720961 DOI: 10.1136/bcr-2021-245405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Ali Sajjad
- Neurology, The Aga Khan University, Karachi, Pakistan
| | | | - Lubna Jafri
- Neurology, The Aga Khan University, Karachi, Pakistan
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14
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Shindo A, Oyama G, Nishikawa N, Hattori N. Varicella-zoster virus encephalitis resembling herpes simplex virus encephalitis. BMJ Case Rep 2021; 14:e247602. [PMID: 34972787 PMCID: PMC8720986 DOI: 10.1136/bcr-2021-247602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Atsuhiko Shindo
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Genko Oyama
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Noriko Nishikawa
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
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15
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Abstract
A 64-year-old woman presented with 24 hours of lethargy, confusion, headache, nausea and vomiting. Examination revealed expressive aphasia, conjunctival suffusion and a tick embedded in her popliteal fossa. Labs revealed hyponatraemia, transaminitis, leucopenia, thrombocytopenia and an elevated C reactive protein. Peripheral blood smear was unremarkable. MRI/magnetic resonance angiogram revealed bilateral frontoparietal subarachnoid haemorrhage which was further confirmed by lumbar puncture which revealed six nucleated cells, 92% lymphocytes, 1460 red blood cells, normal glucose and protein and negative cryptococcal antigen, herpes simplex PCR and Lyme PCR. Serum Lyme IgG/IgM antibodies and PCR, Erlichia chaffeensis serum IgG/IgM antibodies and PCR and anaplasma serum IgG/IgM antibodies were negative. Anaplasmosis serum PCR was positive. The tick was identified as Ixodes scapularis The patient was diagnosed with anaplasmosis and treated with 21 days of doxycycline resulting in improvement of symptoms, but lingering headaches and word finding difficulties.
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Affiliation(s)
- Jon Brandon Mullholand
- Department of Internal Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Nathanial Tolman
- Department of Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Anna De Obaldia
- Department of Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Eileen Hennrikus
- Department of Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
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16
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Howell P, Upton C, Mvuna N, Olugbosi M. Sterile tuberculous granuloma in a patient with XDR-TB treated with bedaquiline, pretomanid and linezolid. BMJ Case Rep 2021; 14:e245612. [PMID: 34876446 PMCID: PMC8655514 DOI: 10.1136/bcr-2021-245612] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2021] [Indexed: 11/04/2022] Open
Abstract
Drug-resistant tuberculosis (DR-TB) continues to pose a threat to the global eradication of TB. Regimens for extensively drug-resistant (XDR) TB are lengthy and poorly tolerated, often with unsuccessful outcomes. The TB Alliance Nix-TB trial investigated the safety and efficacy of a 26-week regimen of bedaquiline, pretomanid and linezolid (BPaL) in participants with XDR-TB, multidrug-resistant (MDR) TB treatment failure or intolerance. In this trial 9 out of 10 participants were cured. We describe a trial participant with XDR-TB who presented with new-onset seizures soon after BPaL treatment completion. Imaging showed a right temporal ring-enhancing lesion, and a sterile tuberculous granuloma was confirmed after a diagnostic, excisional biopsy. Learning points include management of a participant with a tuberculoma after BPaL completion, efficacy of new medications for central nervous system (CNS) TB and a review of their CNS penetration. This is the first case of pretomanid use in CNS TB.
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Affiliation(s)
- Pauline Howell
- Clinical HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Sandringham, South Africa
| | - Caryn Upton
- TASK Applied Sciences, Cape Town, South Africa
| | - Nokuphiwa Mvuna
- Clinical HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Sandringham, South Africa
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17
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Nibourg S, Beudel M, Trip J. Isolated proximal weakness of the legs due to neuroborreliosis. BMJ Case Rep 2021; 14:e244431. [PMID: 34782374 PMCID: PMC8593606 DOI: 10.1136/bcr-2021-244431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 11/03/2022] Open
Abstract
Proximal muscle weakness of the legs is a symptom with a broad differential diagnosis. It is mainly caused by neuromuscular disorders and is often a diagnostic challenge. Here, we present a 73-year-old man with isolated proximal weakness of the legs due to lumbar root involvement on the basis of neuroborreliosis. After treatment with intravenous antibiotics he recovered completely. This is the first described case with isolated proximal muscle weakness of the legs due to neuroborreliosis. Despite the fact neuroborreliosis is a rare cause of proximal muscle weakness of the legs, clinicians should include it in their differential diagnosis, especially since it is a treatable condition.
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Affiliation(s)
- Simone Nibourg
- Neurology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Martijn Beudel
- Neurology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Jeroen Trip
- Neurology, Isala Zwolle, Zwolle, The Netherlands
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18
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Kajtazi NI, Khalid E, Ghamdi JA, Abulaban A, AlHameed MH. Severe ataxia uncovered Hodgkin's lymphoma: do not forget CT neck when looking for covert malignancy. BMJ Case Rep 2021; 14:e245225. [PMID: 34764117 PMCID: PMC8586887 DOI: 10.1136/bcr-2021-245225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 11/04/2022] Open
Abstract
A 53-year-old woman without medical problems presented with 5-month history of dizziness, difficulty speaking, severe ataxia, which worsened a day before admission to inability to stand unsupported. An extensive workup was initiated to find the cause of ataxia. The laboratory investigations and imaging of the brain and whole spine revealed no lesions. She was found to have autoimmune thyroiditis, positive coeliac disease antibodies without clinical features and vitamin D deficiency. No intravenous steroids or immunosuppressive therapy was given. Cerebrospinal fluid showed lymphocytic pleocytosis. The workup for the cause of severe ataxia revealed an oropharyngeal lesion with cervical lymph nodes, and the biopsy showed classical Hodgkin's lymphoma of mixed cellularity. She was treated with chemotherapy followed by radiation therapy and made a remarkable recovery, and currently, she is in remission without distant metastases, 5 years after the initial diagnosis. Her neurological status improved, and she remained with mild ataxia.
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Affiliation(s)
| | - Ehtesham Khalid
- Department of Neurology, Ideal Medicare Clinic, Multan, Punjab, Pakistan
| | - Juman Al Ghamdi
- Medical Imaging Administration, Intervention Neuroradiology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ahmad Abulaban
- Neurology, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Riyadh, Saudi Arabia
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19
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Mouro M, Frade J, Chaves C, Velez J. Helcococcus kunzii, a skin-colonising microorganism with pathogenic capacity: a case of polymicrobial intracranial empyema. BMJ Case Rep 2021; 14:e244600. [PMID: 34753723 PMCID: PMC8578945 DOI: 10.1136/bcr-2021-244600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 11/04/2022] Open
Abstract
Helcococcus kunzii is a Gram-positive anaerobic facultative coccus that colonises the skin. Human infection is rare, with very few cases being described in the literature. The authors present the case of a 17-year-old man, with a history of cholesteatoma, diagnosed with mastoiditis complicated by intracranial empyema. After urgent surgical drainage, Gram staining revealed a Gram-negative bacillus and a Gram-positive coccus. The latter exhibited fastidious growth, presented as small grey colonies in blood agar, and was afterwards identified as H. kunzii The patient was started on intravenous antibiotics, switched to oral route after 8 weeks and fully recovered. To the best of our knowledge, this is the third case of an intracranial infection in which H. kunzii is involved, two of them occurring in patients with cholesteatoma.
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Affiliation(s)
- Margarida Mouro
- Microbiology Laboratory, Clinical Pathology Department, Coimbra Hospital and University Center EPE, Coimbra, Portugal
- Infectious Diseases Department, Baixo Vouga Hospital Center EPE, Aveiro, Portugal
| | - João Frade
- Microbiology Laboratory, Clinical Pathology Department, Coimbra Hospital and University Center EPE, Coimbra, Portugal
| | - Catarina Chaves
- Microbiology Laboratory, Clinical Pathology Department, Coimbra Hospital and University Center EPE, Coimbra, Portugal
| | - Jorge Velez
- Infectious Diseases Department, Baixo Vouga Hospital Center EPE, Aveiro, Portugal
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20
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Suri V, Pandey S, Goyal N, Rani H. Cladophialophora bantiana brain abscess with lymphadenitis. BMJ Case Rep 2021; 14:e246108. [PMID: 34706919 PMCID: PMC8552180 DOI: 10.1136/bcr-2021-246108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2021] [Indexed: 11/04/2022] Open
Abstract
Cerebral phaeohyphomycosis refers to central nervous system infection by dematiaceous mould or by dark walled fungi which contain the dark pigment melanin in their cell wall which adds to the virulence of fungus. These dematiaceous fungi can cause a variety of central nervous infections including invasive sinusitis, brain abscess, meningitis, myelitis and arachnoiditis. Cladophialophora bantiana among these dematiaceous fungi is the most common cause of brain abscess in immunocompetent and immunocompromised individuals and is known to occur worldwide though is predominantly reported from subtropical regions especially the Asian subcontinent. It is difficult to differentiate these abscesses radiologically from high-grade gliomas, primary central nervous system lymphoma or other infections including toxoplasmosis, nocardiosis, tuberculosis and listeriosis. We describe a 19-year-old male patient with a cerebral abscess caused by C. bantiana where the diagnosis could be suspected by typical MR spectroscopic findings and by identifying the fungus from a lymph node biopsy.
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Affiliation(s)
- Vinit Suri
- Neurology, Indraprastha Apollo Hospital, New Delhi, India
| | - Shishir Pandey
- Neurology, Indraprastha Apollo Hospital, New Delhi, India
| | - Nidhi Goyal
- Radio Diagnosis, Indraprastha Apollo Hospital, New Delhi, India
| | - Hena Rani
- Microbiology, Indraprastha Apollo Hospital, New Delhi, India
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21
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Abstract
Herpes zoster reactivation is a frequently encountered condition that can result in several uncommon complications. This case report highlights one such frequently overlooked complication, segmental zoster paresis. We discuss a case of prolonged fever and lower limb weakness in an immunocompromised patient with breast cancer on active chemotherapy after resolution of a herpetiform rash in the L2, L3 and L4 dermatomes. Early investigation with lumbar puncture, looking for cerebrospinal fluid pleocytosis, varicella zoster virus detection by PCR or molecular testing and immunoglobulins against varicella zoster virus, should be undertaken to support the diagnosis. Nerve conduction studies, electromyography and MRI of the spine can sometimes help with neurolocalisation. Intravenous acyclovir and a tapering course of steroids can help with resolution of symptoms. The variegate presentation can make diagnosis challenging. Awareness and a high index of suspicion can prevent delays in diagnosis and treatment and improve patient outcomes.
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Affiliation(s)
| | - Yun Cao
- Department of General Medicine, Tan Tock Seng Hospital, Singapore
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22
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Patel L, Elavarasi A, Garg A, Nambirajan A. Cerebellar progressive multifocal leukoencephalopathy associated with pulmonary sarcoidosis. BMJ Case Rep 2021; 14:e245271. [PMID: 34580133 PMCID: PMC8477238 DOI: 10.1136/bcr-2021-245271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2021] [Indexed: 11/04/2022] Open
Abstract
Progressive multifocal leukoencephalopathy can complicate the course of a patient with sarcoidosis. Here we present a rare case of a 35-year-old patient with pulmonary sarcoidosis whose course was complicated by progressive multifocal leukoencephalopathy involving the cerebellum. Neuroimaging and cerebrospinal fluid PCR played a crucial role in the diagnosis.
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Affiliation(s)
- Lajjaben Patel
- All India Institute of Medical Sciences, New Delhi, Delhi, India
| | | | - Ajay Garg
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Aruna Nambirajan
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, Delhi, India
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23
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Murali S, Shenoy SV, Prabhu RA, Nagaraju SP. Hypertensive emergency and seizures during haemodialysis. BMJ Case Rep 2021; 14:e242471. [PMID: 34548293 PMCID: PMC8458320 DOI: 10.1136/bcr-2021-242471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 11/04/2022] Open
Abstract
Intracranial abscesses are uncommon, serious and life-threatening infections. A brain abscess is caused by inflammation and collection of infected material, coming from local or remote infectious sources. Patients with chronic kidney disease on dialysis are prone to invasive bacterial infections like methicillin-resistant Staphylococcus aureus (MRSA) especially in the presence of central venous catheters or arteriovenous grafts. However, intracranial abscess formation due to MRSA is rare. Here, we present a case of MRSA brain abscess with an atypical clinical presentation in the absence of traditional risk factors.Intracranial abscesses are uncommon, serious, and life-threatening infections. A Brain abscess is caused by inflammation and collection of infected material, coming from local or remote infectious sources. Patients with chronic kidney disease on dialysis are prone to invasive bacterial infections like methicillin-resistant staphylococcus aureus (MRSA) especially in the presence of central venous catheters or arterio-venous grafts. However intracranial abscess formation due to MRSA is rare. Here we present a case of MRSA brain abscess with an atypical clinical presentation in the absence of traditional risk factors. A 46-year-old male with chronic kidney disease (CKD) secondary to chronic glomerulonephritis, on haemodialysis for 4 years through a left brachio-cephalic AVF developed an episode of generalised tonic-clonic seizures lasting 2 min during his scheduled dialysis session. He reported no complaints before entry to the dialysis. On clinical examination, he was drowsy with the absence of any focal motor deficits. His blood pressure was recorded to be 200/120 mm Hg. He was managed in the intensive care unit with mechanical ventilation, intravenous nitroglycerine for blood pressure control, levetiracetam for seizures and empirical vancomycin. Radiological evaluation showed a brain abscess in the midline involving bosth basi-frontal lobes. After medical optimization, the abscess was drained surgically, and the pus cultured. As culture grew Methicillin Resistant Staphylococcus aureus, he was treated with intravenous vancomycin for 6 weeks. On follow up, the abscess had resolved and the patient recovered without any neurological deficits.
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Affiliation(s)
| | | | - Ravindra Attur Prabhu
- Department of Nephrology, Kasturba Medical College Manipal, Manipal, Karnataka, India
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24
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Ozolina E, Auslands K, Buks M, Ansons M. Propionibacterium acnes causing non-contiguous, multifocal spondylodiscitis in an immunosuppressed patient. BMJ Case Rep 2021; 14:e242420. [PMID: 34544700 PMCID: PMC8454287 DOI: 10.1136/bcr-2021-242420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 11/04/2022] Open
Abstract
This report describes a case of a spondylodiscitis in an immunocompromised patient with an HIV infection caused by Propionibacterium acnes The patient was admitted to hospital with a sudden loss of motor function and sensation in both of the patient's legs. A biopsy taken during the first debridement operation proved to be negative for Mycobacterium tuberculosis DNA and growth, but was positive for the growth of P. acnes Following a course of antibiotic therapy and the aforementioned debridement, the patient was moved to a specialised clinic for physical therapy. The patient's condition quickly deteriorated, and the patient once again required extensive debridement. Repeated spinal surgery, antibiotics for 12 weeks and subsequent rehabilitation resulted in almost complete recovery of sensorimotor limb function.
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Affiliation(s)
- Elina Ozolina
- Department of Neurology and Neurosurgery, Rigas Austrumu kliniska universitates slimnica, Riga, Latvia
| | - Kaspars Auslands
- Department of Neurology and Neurosurgery, Rigas Austrumu kliniska universitates slimnica, Riga, Latvia
| | - Maris Buks
- Department of Neurology and Neurosurgery, Rigas Austrumu kliniska universitates slimnica, Riga, Latvia
| | - Martins Ansons
- Faculty of Medicine, Rīga Stradiņš University, Riga, Latvia
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25
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Karna R, Hans B, Murone J, Black J. Cranial nerve palsies, SIADH and atrial fibrillation: a diagnostic challenge. BMJ Case Rep 2021; 14:e244807. [PMID: 34521742 PMCID: PMC8442043 DOI: 10.1136/bcr-2021-244807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 11/03/2022] Open
Abstract
We recently encountered a 79-year-old Caucasian man who presented with blurring of vision and facial muscle weakness. The patient also had hyponatraemia, atrial fibrillation with rapid ventricular response and underlying Brugada type II pattern. Urine and serum osmolality were consistent with syndrome of inappropriate antidiuretic hormone secretion (SIADH). It was only after extensive imaging and workup that we were able to tie together these three different presentations of Lyme disease-cranial nerve palsies, SIADH and atrial fibrillation and treat them accordingly. To the best of our knowledge, only eight cases of SIADH in patients with Lyme neuroborreliosis have been reported in the literature. Although our patient did not have a history of arrhythmias, case findings suggest that underlying Brugada type II morphology could have been the predisposing factor, and Lyme disease the trigger.
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Affiliation(s)
- Rahul Karna
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Bandhul Hans
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Julie Murone
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - John Black
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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26
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Vidhale TA, Gupta HR, Prafulla Jaya R, Pustake M. Fulminant subacute sclerosing panencephalitis (SSPE) presented with acute hemiparesis in a 13-year-old girl with perinatally acquired HIV infection. BMJ Case Rep 2021; 14:e241205. [PMID: 34518172 PMCID: PMC8438743 DOI: 10.1136/bcr-2020-241205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 11/03/2022] Open
Abstract
A 13-year-old girl with perinatally acquired HIV infection was admitted to us with acute onset, right-sided hemiparesis of 30 days duration and right-sided myoclonic jerks of 2 days duration affecting the face, upper and lower limbs. On examination, she exhibited increased tone and a pyramidal pattern of weakness in her right upper and lower limbs, along with spontaneous multifocal myoclonic jerks in the affected area. IgG levels in the serum and cerebrospinal fluid for measles were significantly elevated. Brain MRI depicted T2-weighted-hyperintensities in the subcortical white matter. The electroencephalogram demonstrated evidence of lateralised long interval periodic discharges. This patient had no past behavioural problems or poor academic performance. This case underlines the fact that, though subacute sclerosing panencephalitis (SSPE) is a chronic disease, a rare fulminant form of SSPE might develop acutely and atypically, with an increased proclivity for HIV-infected patients.
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Affiliation(s)
- Tushar Ashok Vidhale
- General Medicine, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
| | - Hemant R Gupta
- General Medicine, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
| | - Rohan Prafulla Jaya
- Department of Radiology, BGS Global Institute of Medical Sciences, Bangalore, Karnataka, India
| | - Manas Pustake
- General Medicine, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
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27
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Sumangala S, Htwe T, Ansari Y, Martinez-Alvarez L. Primary leptomeningeal lymphoma masquerading as infectious tubercular meningitis. BMJ Case Rep 2021; 14:e243574. [PMID: 34518180 PMCID: PMC8438867 DOI: 10.1136/bcr-2021-243574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 01/13/2023] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is infrequent and often poses diagnostic conundrums due to its protean manifestations. We present the case of a South Asian young man presenting with raised intracranial pressure and a lymphocytic cerebrospinal fluid (CSF) with pronounced hypoglycorrhachia. Progression of the neuro-ophthalmic signs while on early stages of antitubercular treatment led to additional investigations that produced a final diagnosis of primary leptomeningeal lymphoma. Treatment with chemoimmunotherapy (methotrexate, cytarabine, thiotepa and rituximab (MATRix)) achieved full radiological remission followed by successful autologous transplant. This case highlights the difficulties and diagnostic dilemmas when PCNSL presents as a chronic meningeal infiltrative process. While contextually this CSF is most often indicative of central nervous system tuberculosis and justifies empirical treatment initiation alone, it is essential to include differential diagnoses in the investigation work-up, which also carry poor prognosis without timely treatment. High suspicion, multidisciplinary collaboration and appropriate CSF analysis were the key for a correct diagnosis.
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Affiliation(s)
- Salini Sumangala
- Department of Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Thidar Htwe
- Department of Respiratory Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Yousuf Ansari
- Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Department of Ophthalmology, Birmingham and Midland Eye Centre, Birmingham, UK
| | - Lidia Martinez-Alvarez
- Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Department of Ophthalmology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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28
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Affiliation(s)
- Kritika Sharma
- Radiodiagnosis, Pacific Institute of Medical Sciences, Udaipur, Rajasthan, India
| | - Tapendra Tiwari
- Radiodiagnosis, Pacific Institute of Medical Sciences Umarda Campus, Udaipur, India
| | - Saurabh Goyal
- Radiodiagnosis, Pacific Institute of Medical Sciences Umarda Campus, Udaipur, India
| | - Rajaram Sharma
- Radiodiagnosis, Pacific Institute of Medical Sciences Umarda Campus, Udaipur, India
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29
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Jaiswal AS, Kumar R, Sagar P, Kumar R. Acute-onset isolated bilateral palatal palsy in an adolescent. BMJ Case Rep 2021; 14:e243467. [PMID: 34479886 PMCID: PMC8420686 DOI: 10.1136/bcr-2021-243467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 11/04/2022] Open
Abstract
A 16-year-old patient presented with sudden-onset difficulty in swallowing food especially for liquids with nasal regurgitation and rhinolalia with no history of fever and limb weakness. Examination revealed bilateral palatal palsy with absence of gag reflex. Other neurological examinations were normal. Investigations were done to rule out any known pathology leading to such a presentation. The symptoms were attributed to an idiopathic acute-onset-acquired bilateral palatal palsy, in the absence of any identifiable cause. This is a rare presentation in adolescent age with no case reported in the literature so far in this age group. Medical management was started and patient showed complete improvement within 2 weeks of his symptoms. Early diagnosis and aggressive management of this condition lead to a favourable prognosis.
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Affiliation(s)
- Avinash Shekhar Jaiswal
- Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Rajeev Kumar
- Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Prem Sagar
- Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Rakesh Kumar
- Otorhinolaryngology and Head & Neck Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
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30
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Tamura H, Ishizuka K, Mori T, Ikusaka M. Varicella zoster virus meningitis with rashes masked by a mask as a precaution for COVID-19. BMJ Case Rep 2021; 14:14/8/e245102. [PMID: 34404671 PMCID: PMC8372800 DOI: 10.1136/bcr-2021-245102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Hiroki Tamura
- Department of General Medicine, Chiba University Hospital Department of General Medicine, Chiba, Japan
- Department of General Internal Medicine, Eastern Chiba Medical Center, Togane, Japan
| | - Kosuke Ishizuka
- Department of General Medicine, Chiba University Hospital Department of General Medicine, Chiba, Japan
- Department of General Internal Medicine, Eastern Chiba Medical Center, Togane, Japan
| | - Takahiro Mori
- Department of General Internal Medicine, Eastern Chiba Medical Center, Togane, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital Department of General Medicine, Chiba, Japan
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31
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Akbar A, Ahmad S. Atypical case of mild encephalopathy/encephalitis with reversible splenial lesion of the corpus callosum (MERS) associated with Mycoplasma pneumoniae infection in a paediatric patient. BMJ Case Rep 2021; 14:e242791. [PMID: 34389590 PMCID: PMC8365810 DOI: 10.1136/bcr-2021-242791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 11/04/2022] Open
Abstract
Mild encephalopathy with reversible splenial lesion (MERS) is a disorder characterised by prodromal symptoms such as fever, cough, vomiting or diarrhoea, followed by mild encephalopathy 1-7 days later with a documented reversible corpus callosum splenial lesion. MERS is mostly reported in children in the region of East Asia. To the best of our knowledge, this is the first reported case of MERS associated with mycoplasma infection in a child in North America. A brief review of literature is also a part of this report.
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Affiliation(s)
- Asra Akbar
- Pediatric Neurology, UICOMP, Peoria, Illinois, USA
| | - Sharjeel Ahmad
- Internal Medicine, Section of Infectious Diseases, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
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32
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Abstract
Vancomycin is a widely used antibiotic and rarely can cause drug-induced thrombocytopenia. A patient with hospital-acquired meningitis after neurosurgery was treated with systemic and intrathecal vancomycin. On 9th day of antibiotic treatment, the patient's platelets dropped to 0.68×109/L. Multiple platelet transfusions had minimal influence on platelet count. After cessation of vancomycin therapy, platelets returned to normal values without any additional interventions. Diagnosis of vancomycin-induced thrombocytopenia was confirmed by detection of drug-dependent antiplatelet IgG antibodies.
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Affiliation(s)
- Ian Savchenko
- Intensive Care, National Medical Research Center for Neurosurgery Named After NN Burdenko, Moscow, Russian Federation
| | - Tatiana Birg
- Intensive Care, National Medical Research Center for Neurosurgery Named After NN Burdenko, Moscow, Russian Federation
| | - Oleg Sharipov
- Neurosurgery, National Medical Research Center for Neurosurgery Named After NN Burdenko, Moscow, Russian Federation
| | - Yulia Davydova
- Laboratory for Immunophenotyping of Blood and Bone Marrow Cells, FSBI National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
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33
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Sindgikar SP, Narayanaswamy B, Alexander LM, Kanavu R. Paradoxical immune reconstitution inflammatory syndrome in neurotuberculosis. BMJ Case Rep 2021; 14:e243739. [PMID: 34376417 PMCID: PMC8356154 DOI: 10.1136/bcr-2021-243739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 11/03/2022] Open
Abstract
Tuberculosis (TB) remains the most common infection in developing countries and India contributes the maximum number of cases to the global burden. Primary healthcare physicians across the country face major challenges in diagnosis and treatment of childhood TB. In this context, clinical cases of paradoxical responses to antitubercular therapy seem to be under-reported. We report a case of tubercular meningitis in an adolescent girl who belonged to a remote village. She developed a paradoxical immune response to TB while on anti-TB treatment (ATT). She presented with raised intracranial tension and neurological deficits during the continuation phase of ATT after stopping corticosteroids. The ring-enhancing lesions of tuberculomas in the brain and spine characterised the diagnosis of paradoxical response to TB. Brain biopsy suggested necrotising granulomatous disease and was negative for S100 and CD1a marker, ruling out active TB. Retreatment with a prolonged course of steroids and ATT resulted in the clinical and radiological recovery, though some motor and visual deficits persisted. Clinical risk factors and socioeconomic factors also contributed to the present state of the child.
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Affiliation(s)
- Seema Pavaman Sindgikar
- Pediatric, KS Hegde Medical Academy (KSHEMA), NITTE (Deeemed to be Univeristy), Mangalore, Karntaka, India
| | - Bindu Narayanaswamy
- Pediatric, KS Hegde Medical Academy (KSHEMA), NITTE (Deeemed to be Univeristy), Mangalore, Karntaka, India
| | - Lobo Manuel Alexander
- Neurology, KS Hegde Medical Academy (KSHEMA), NITTE (Deemed to be Univeristy), Mangalore, Karnataka, India
| | - Ramkishore Kanavu
- Radiology, KS Hegde Medical Academy (KSHEMA), NITTE (Deemed to be Univeristy), Mangalore, Karnataka, India
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34
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Connor S, Azzam O, Prentice D. Intracerebral haemorrhage and Guillain-Barré syndrome: an exploration of potential pathophysiology. BMJ Case Rep 2021; 14:14/8/e243245. [PMID: 34344649 PMCID: PMC8336193 DOI: 10.1136/bcr-2021-243245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an immune-mediated polyneuropathy classically thought to be caused by infections through the process of molecular mimicry. We report a case of GBS caused by intracerebral haemorrhage and postulate potential theories for the development of GBS following intracerebral haemorrhage and other non-infectious aetiologies by association. We highlight that GBS is an important differential diagnosis in patients developing generalised paresis following intracerebral haemorrhage.
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Affiliation(s)
- Sophia Connor
- Royal Perth Hospital, Perth, Western Australia, Australia
| | - Omar Azzam
- General Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - David Prentice
- General Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
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35
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Briner M, Oberholzer M, Wagner F, Chan A. Potential disease trigger as a therapeutic option: infliximab for paradoxical reaction in tuberculosis of the central nervous system. BMJ Case Rep 2021; 14:14/8/e235511. [PMID: 34340991 PMCID: PMC8330559 DOI: 10.1136/bcr-2020-235511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 36-year-old man of central Asian origin was diagnosed with subacute disseminated tuberculosis. Initially, central nervous system involvement was suggested by an encephalopathic condition and MRI showing extensive basal and spinal meningitis. After initiation of anti-tuberculosis drugs and corticosteroid therapy, clinical and radiological deterioration of spinal damage was noted. We interpreted this in the context of a paradoxical reaction, which is suggested to be an overshooting inflammatory response after reconstitution of the immune system. Despite increased dosage of corticosteroids, a gradual worsening of gait ataxia over several weeks was noted. After administration of infliximab, the patient's condition progressively improved.
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Affiliation(s)
- Myriam Briner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Michael Oberholzer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Franca Wagner
- Diagnostic and Interventional Neuroradiology, Inselspital University Hospital Bern, 3010 Bern, Switzerland
| | - Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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36
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Affiliation(s)
- Navneet Arora
- Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Devender Kumar
- Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravindran Kiran
- Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar Pannu
- Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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37
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O'Riordan F, Ronayne A, Jackson A. Capnocytophaga canimorsus meningitis and bacteraemia without a dog bite in an immunocompetent individual. BMJ Case Rep 2021; 14:14/7/e242432. [PMID: 34290010 DOI: 10.1136/bcr-2021-242432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We describe the case of an immunocompetent 75-year-old man with Capnocytophaga canimorsus bacteraemia and meningitis. C. canimorsus is commonly found in the oral flora of dogs with human infection typically occurring following a bite. Unusually, while our patient was a dog owner, there was no history of bite nor scratch mark. Admission blood cultures flagged positive for Gram-negative bacilli, but prolonged molecular analysis was required before C. canimorsus was isolated in blood and cerebrospinal fluid. There is a high mortality rate in invasive infection, and in our patient's case, antibiotic therapy was commenced prior to laboratory confirmation with our patient making a complete recovery. This case highlights the importance of including C. canimorsus in the differential diagnosis of unwell patients who keep dogs, even without a bite. This case occurred amid heightened awareness of COVID-19, which may represent predisposition for zoonoses during social isolation and increased human-pet contact.
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Affiliation(s)
| | - Aoife Ronayne
- Microbiology, Mercy University Hospital, Cork, Ireland
| | - Arthur Jackson
- Infectious Diseases, Mercy University Hospital, Cork, Ireland
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38
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Abstract
A 52-year-old woman with HIV and recent antiretroviral therapy non-adherence presented with a 5-day history of widespread painful vesicular skin lesions. Direct fluorescent antibody testing of the skin lesions was positive for varicella zoster virus (VZV). On day 3, she developed profound right upper extremity weakness. MRI of the brain and cervical spine was suggestive of VZV myelitis. Lumbar puncture was positive for VZV PCR in the cerebrospinal fluid (CSF) and CSF HIV viral load was detected at 1030 copies/mL, indicating 'secondary' HIV CSF escape. She was treated with intravenous acyclovir for 4 weeks and subsequent oral therapy with famciclovir then valacyclovir for 6 weeks. She also received dexamethasone. The patient had an almost full recovery at 6 months. Myelitis is a rare complication of reactivated VZV infection that can have atypical presentation in immunocompromised patients. Such 'secondary' HIV CSF escape should be considered in immunosuppressed patients with concomitant central nervous system infection.
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Affiliation(s)
- Julian J Weiss
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA.,Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Serena Spudich
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lydia Barakat
- Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
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39
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Abstract
Syphilis is increasingly prevalent in the community. The protean manifestations of neurosyphilis make the recognition, diagnosis and early initiation of treatment challenging. We report a case of early syphilitic meningitis presenting with multiple cranial neuropathies. Cerebrospinal fluid (CSF) examination was inflammatory with predominant lymphocytosis. The patient was diagnosed with neurosyphilis based on serum as well as CSF testing. Intravenous benzylpenicillin treatment resulted in rapid improvement of neurological symptoms. Neurosyphilis should be considered in immunocompetent patients presenting with multiple cranial neuropathies, or isolated cranial neuropathies without vascular risk factors.
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Affiliation(s)
- Melissa Chu
- Gosford Hospital, Gosford, New South Wales, Australia
| | - Shejil Kumar
- Gosford Hospital, Gosford, New South Wales, Australia
| | - Jonathan Sturm
- Neurology, Gosford Hospital, Gosford, New South Wales, Australia
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40
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Carr K, Ogbuagu O. Late neurosyphilis and VZV meningoencephalitis coinfection. BMJ Case Rep 2021; 14:14/6/e240412. [PMID: 34162599 DOI: 10.1136/bcr-2020-240412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The incidence of syphilis has increasing recently, largely attributable to improved screening that may result in the diagnosis of chronic untreated infections. These patients can develop severe or subtle neurologic symptoms that can be missed and, therefore, detected accidentally while a patient is evaluated for other mimicking neurological infections. A 58-year-old man with diabetes presented with 2 days of aphasia, headache, chills and confusion. He had an MRI brain with evidence of a prior cerebrovascular accident. Subsequently, he developed a fever and thoracic dermatomal rash consistent with herpes zoster. A lumbar puncture was performed, and cerebrospinal fluid analysis revealed a lymphocytic pleocytosis, a reactive Venereal Disease Research Laboratory test and positive varicella-zoster virus (VZV) PCR. He was suspected to have both late neurosyphilis and acute meningoencephalitis from VZV. This paper will discuss how to approach the diagnosis of late neurosyphilis and possible associations with herpesvirus central nervous system infections.
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Affiliation(s)
- Kristin Carr
- Infectious Diseases, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Onyema Ogbuagu
- Infectious Diseases, Yale-New Haven Hospital, New Haven, Connecticut, USA
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41
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Sirur FM, Daswaney A, Raghu R, Khalid M. Pneumocephalus with meningitis secondary to an old traumatic anterior cranial fossa defect. BMJ Case Rep 2021; 14:14/6/e242855. [PMID: 34116999 DOI: 10.1136/bcr-2021-242855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a case of a 30-year-old man who presented with altered mental status, fever, headache and vomiting for 3 days. An initial CT scan of the brain revealed the presence of pneumocephalus with a bony defect in the anterior cranial fossa. The pneumocephalus was not explained initially and the patient was re-examined for any signs of trauma to the face, and a review of the history revealed a series of three traumatic events months prior to this illness. Further laboratory studies revealed Streptococcus pneumoniae in the blood and bacterial meningitis. He was treated with antibiotics and was later taken up for endoscopic repair of the skull base defect. This case highlights the importance of recognising post-traumatic pneumocephalus with superimposed meningitis and sepsis months after a traumatic event to the skull base.
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Affiliation(s)
- Freston Marc Sirur
- Emergency Medicine, Kasturba Hospital Manipal, Manipal, Karnataka, India.,Kasturba Medical College, Manipal, Karnataka, India
| | - Akash Daswaney
- Emergency Medicine, Kasturba Hospital Manipal, Manipal, Karnataka, India .,Kasturba Medical College, Manipal, Karnataka, India
| | | | - Mohammad Khalid
- Emergency Medicine, Kasturba Hospital Manipal, Manipal, Karnataka, India.,Kasturba Medical College, Manipal, Karnataka, India
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42
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Abstract
Brainstem abscess is an uncommon occurrence in itself and an abscess in the medulla oblongata is even rarer. Although these abscesses have established association with head and neck infections, we report the first known case of medullary abscess that was found to be strongly associated with dental procedure. Important point to note is that a simple procedure like tooth extraction can predispose spread of infective seeding to distant sites. High clinical index of suspicion and early diagnosis are essential, as if left untreated, the brainstem abscess is almost always fatal otherwise.
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Affiliation(s)
- Amit Verma
- Department of Medicine, East Sussex Healthcare NHS Trust, Eastbourne, East Sussex, UK
| | - Saad Qutab
- Respiratory Medicine, Conquest Hospital, Hastings, East Sussex, UK
| | - Mahum Baig
- Department of Medicine, East Sussex Healthcare NHS Trust, Eastbourne, East Sussex, UK
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43
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Abstract
Human T-lymphotropic virus type I (HTLV-I) is a retrovirus associated with adult T-cell lymphoma (ATL) and HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP). In addition to HAM/TSP and ATL, HTLV-I-associated encephalopathy and cerebellar involvement have been reported. We report a case of an 87-year-old Japanese woman presenting with progressive dysarthria and gait disturbance. Neurological examination showed word-finding difficulty, scanning speech, saccadic eye movements, ocular dysmetria, gaze-evoked nystagmus and bilateral dysmetria. There was no motor weakness or spasticity. HTLV-I antibody was detected in both her serum and cerebrospinal fluid. Cerebrospinal fluid neopterin (57 pg/mL) and IgG index (3.27) were significantly elevated. MRI showed cerebellar swelling. She was finally diagnosed with HTLV-I associated cerebellitis. Two courses of high-dose intravenous methylpredonine therapy attenuated cerebellar ataxia and cerebellar swelling. It suggests that cerebellitis can result from HTLV-I infection, regardless of the existence of ATL or HAM/TSP.
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Affiliation(s)
- Atsushi Mizuma
- Department of Neurology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Kumiko Enokida
- Department of Neurology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Eiichiro Nagata
- Department of Neurology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Shunya Takizawa
- Department of Neurology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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44
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Vazquez-Guevara D, Badial-Ochoa S, Caceres-Rajo KM, Rodriguez-Leyva I. Catatonic syndrome as the presentation of encephalitis in association with COVID-19. BMJ Case Rep 2021; 14:14/6/e240550. [PMID: 34088685 PMCID: PMC8183207 DOI: 10.1136/bcr-2020-240550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
COVID-19 has shown different neurological manifestations even sometimes there are the initial or the main presentation. The following case report is about a middle-aged woman who, over 3 days, developed fever, clinical neurological alterations (stupor, muteness, fixed gaze and catatonia), cerebrospinal fluid (16 lymphocytes) and an electroencephalogram (EEG) (4–6 Hz generalised activity) with characteristics of encephalitis. A serum IgG, IgM, nasopharyngeal swab PCR for SARS-CoV-2. The patient responded positively to support measures, symptomatic and corticosteroid treatment. At discharge, the patient was independent and improved considerably. We report the presence of catatonia as a possible and atypical manifestation of encephalitis in association with COVID-19.
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Affiliation(s)
| | - Sandra Badial-Ochoa
- Neurology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico
| | - Karen M Caceres-Rajo
- Internal Medicine, Facultad de Medicina, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Ildefonso Rodriguez-Leyva
- Neurology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico .,Facultad de Medicina, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
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45
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Abstract
Scrub typhus is a zoonosis, which usually manifests as an acute febrile illness. It is caused by a rickettsia, Orientia tsutsugamushi, which is endemic in the Asian region. It can present with varied clinical manifestations, ranging from acute febrile illness to life-threatening multiorgan dysfunction syndrome. Central nervous system involvement in the form of altered sensorium and/or meningitis is frequently observed in scrub typhus. However, isolated cranial nerve involvement is uncommon and so far only a few such cases have been reported in the literature. We present a rare case of scrub typhus with fever and diplopia at presentation, which completely improved with doxycycline-based treatment.
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Affiliation(s)
- Ajay Chauhan
- Internal Medicine, Civil Hospital, Baddi, Distt Solan, Distt Bilaspur, India
| | - Aditya Jandial
- Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Kundan Mishra
- Internal Medicine, Army Hospital Research and Referral, New Delhi, India
| | - Rajeev Sandal
- Radiotherapy and Oncology, Indira Gandhi Medical College Cancer Hospital, Shimla, India
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46
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Toro J, Rivera JS, Moutran-Barroso H, Valencia-Enciso N. Acute HSV and anti-NMDA encephalitis occurring as a neurosurgical complication. BMJ Case Rep 2021; 14:14/5/e241136. [PMID: 34039543 DOI: 10.1136/bcr-2020-241136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a 24-year-old man with a 2-year history of progressive right-sided monocular vision loss with no other symptoms. An MRI showed a meningioma compressing the right optic nerve and the cavernous sinus. The tumour was partially resected. Eight days after discharge the patient was admitted with fever, a severe stabbing headache, insomnia, nausea and vomiting. A FilmArray panel and a cerebral biopsy were performed which were positive for herpes simplex virus 1 (HSV-1). An MRI of the brain showed asymmetric bilateral lesions in the frontobasal region with predominance of the right side. Acyclovir was started and continued until completing 21 days. A month after discharge, he started experiencing insomnia, trichotillomania, limb tremor, persistence of abulia, apathy and emotional lability. An HSV-1 encephalitis relapse was suspected, acyclovir and foscarnet were started. Due to the poor response to antiviral therapy CSF was tested, which was positive for anti-NMDA receptor encephalitis. A treatment course of intravenous immunoglobulin was started with a favourable outcome.
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Affiliation(s)
- Jaime Toro
- Neurology, Fundacion Santa Fe de Bogota, Bogota, Colombia
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47
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Priyadarshi M, Arora U, Jorwal P. Toxoplasmosis and tuberculosis: brain lesions in HIV/AIDS differentiated by response to therapy. BMJ Case Rep 2021; 14:14/5/e243470. [PMID: 34039556 DOI: 10.1136/bcr-2021-243470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Megha Priyadarshi
- Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Umang Arora
- Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Pankaj Jorwal
- Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India
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48
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Ladzinski AT, George NB, Jagger BW. Bilateral peripheral facial paralysis during pregnancy: a presentation of acute HIV seroconversion. BMJ Case Rep 2021; 14:14/5/e242150. [PMID: 34035026 DOI: 10.1136/bcr-2021-242150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A G7P5A1 woman in her 40s presented to the emergency department at 37 weeks 3 days' estimated gestational age (EGA) with headache, lip tingling and several days of difficulty speaking. Physical examination demonstrated bilateral facial weakness in a peripheral distribution, as well as decreased corneal reflexes and cervical lymphadenopathy. Routine fourth generation HIV screening had previously been negative at 14 and 28 weeks' EGA. Brain MRI was unremarkable, and lumbar puncture disclosed a low-grade, mononuclear cerebrospinal fluid pleocytosis; the patient was treated supportively. She returned for induction of labour at 39 weeks, at which time HIV infection was unexpectedly diagnosed. While unilateral idiopathic peripheral facial paralysis is associated with the third trimester of pregnancy and the early postpartum period, bilateral facial paralysis is rare and should prompt work-up for an underlying systemic cause, such as HIV infection.
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Affiliation(s)
- Adam T Ladzinski
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Nicholas B George
- Departments of Medicine and Pediatric & Adolescent Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Brett W Jagger
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
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49
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Essajee F, Solomons R, Goussard P, Van Toorn R. Acquired unilateral upper limb hypertrophy as a late complication of tuberculous meningitis complicated by Chiari 1 malformation and syringomyelia. BMJ Case Rep 2021; 14:14/5/e240413. [PMID: 34035015 DOI: 10.1136/bcr-2020-240413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Syringomyelia associated with tuberculous meningitis (TBM) is an extremely rare condition. Only a few adult cases have been reported. A 12-year-old woman, who previously suffered TBM at the age of 6 months, presented with a long-standing history of right upper limb panhypertrophy, dissociate anaesthesia, frequent headaches, scoliosis and acquired macrocephaly. MRI demonstrated hydrocephalus, descent of the cerebral tonsils and an intramedullary syrinx extending from C2 to L1. Endoscopic third ventriculostomy (ETV) leads to reduction in the size of the syringomyelia and resolution of the thermoanaesthesia. This case highlights a very rare long-term complication associated with childhood TBM and the potential benefit offered by ETV.
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Affiliation(s)
- Farida Essajee
- Paediatrics and Child Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Regan Solomons
- Paediatrics and Child Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Pierre Goussard
- Paediatrics and Child Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Ronald Van Toorn
- Paediatrics and Child Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
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50
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Wong CK, Ng CF, Tan HJ, Mukari SAM. Bickerstaff brainstem encephalitis with Guillain-Barré syndrome overlap following chlamydia infection. BMJ Case Rep 2021; 14:14/5/e242090. [PMID: 34031085 DOI: 10.1136/bcr-2021-242090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Bickerstaff brainstem encephalitis (BBE) is a rare autoimmune encephalitis characterised by ataxia, ophthalmoplegia and altered consciousness. An overlap between BBE with Guillain-Barré syndrome (GBS) shows similar clinical and immunological features. We report a case of BBE with GBS overlap secondary to Chlamydia pneumoniae infection. The triad of altered consciousness, ataxia and ophthalmoplegia were present in the patient. The investigations included cerebrospinal fluid cytoalbuminological dissociation, nerve conduction test that showed prolonged or absent F wave latencies, hyperintensity in the left occipital region on brain MRI and diffuse slow activity on the electroencephalogram. The chlamydia serology was positive indicating a postinfectious cause of BBE syndrome. He required artificial ventilation as his consciousness level deteriorated with tetraparesis, oropharyngeal and respiratory muscle weakness. Immunotherapy with intravenous immunoglobulin and methylprednisolone was commenced. He made good recovery with the treatment. Prompt recognition of this rare condition following chlamydia infection is important to guide the management.
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Affiliation(s)
- Chee Keong Wong
- Department of Medicine, Hospital Pulau Pinang, Georgetown, Pulau Pinang, Malaysia
| | - Chen Fei Ng
- Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Hui Jan Tan
- Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
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